Addressing micronutrient deficiencies associated with the double burden of childhood malnutrition in China, a combined food system framework

营养不良双重负担（DBM）是一个概念，描述了在同一社区内，特别是在低收入和中等收入国家（LMICs），营养不足和营养过剩日益普遍。这两种营养不良因素都会造成疾病负担。两者的共同点是缺乏微量营养素（MND），如铁、锌和维生素，所有这些都是健康生长和发育以及维持总体健康和生产力所必需的。在中国，尽管经济快速发展，但数千万生活在农村贫困社区的人缺乏食物多样性，经常营养不足，而由于不健康的饮食和不平衡的能量摄入，城市人口的肥胖人数迅速上升。这种与DBM相关的微量营养素缺乏（MND）在儿童中尤其成问题。在“健康中国2030”国家发展战略的“营养第一”框架下，开展了以大豆为基础的儿童微量营养素补充包“应养宝”、富含铁、锌、维生素a等微量营养素的生物强化作物等干预措施，并开展了营养教育和食物多样性。这些措施已被证明对改善营养不良/营养不良儿童的营养是有效的。然而，在营养试验之外，促进这些干预措施的采用存在挑战。结合英国和中国在营养和食品系统方面的专业知识，当前研究的重点是确定采用此类干预措施的障碍，并探索促进其采用的新方法，以改善儿童营养和健康为总体目标。食物是中国文化的重要组成部分。一些被认为是健康的食物，如红薯、小米等，已经过时了，被视为穷人的食物。另一方面，对于像YYB这样不熟悉的食品，儿童可能会有一种固有的抵抗力，以及对食品安全和生物强化的担忧。我们将测试不同年龄组儿童对特定环境干预措施的接受程度。在贫困地区的儿童中，将在6个月至2岁的儿童中测试早期接触YYB对提高接受度的益处。根据早期接触和摄取假设，将在幼儿园和学龄儿童中测试生物强化食品（锌+/铁+小麦和b-胡萝卜素+甘薯）的接受程度。对于有肥胖风险的城市学龄儿童，干预措施将侧重于增加饮食的多样性和优化营养成分。将在学校、家庭和社区各级采用调查方法，研究增强膳食多样性、食物补充和生物强化以及营养知识教育的可行性测试。我们的研究将与当地社区，家庭，特别是母亲合作，探索营养不良和MND的决定因素，以及接受营养干预的社会和文化障碍。当确定了接受的障碍和驱动因素后，将使用讲故事的方法来突出积极信息的摄影展览来促进当地社区的干预措施，并通过社交媒体活动来传播信息并促进参与。我们将为营养不良/MND制定可扩展的粮食系统干预方案，并将其纳入国家粮食和卫生政策和指南。我们将通过沟通和能力建设活动与越南专家合作，扩大营养干预措施的潜在受益者。

The double burden of malnutrition (DBM) is a concept that describes the increasing prevalence of both undernutrition and overnutrition within the same communities, especially in low- and middle-income countries (LMICs). Both of these elements of malnutrition contribute to the burden of disease. Common to both are deficiencies in micronutrients (MND) such as iron, zinc, and vitamins, all of which are needed for healthy growth and development as well as maintaining general health and productivity. In China, despite rapid economic development, tens of millions living in rural poor communities lack food diversity and are frequently nutrient deficient, whilst urban populations show a rapid rise of obesity owing to unhealthy diets and imbalanced energy intake. Such micronutrient deficiencies (MND) associated with DBM are particularly problematic in children. Within the "Nutrition First" program under the "Healthy China 2030" national development strategies, interventions such as Ying Yang Bao (YYB), a soybean-based micronutrient supplementation package targeted at children, and biofortified crops with enriched micronutrients iron, zinc, and vitamin A etc., together with nutrition education and food diversity have been developed. These have been shown to be effective at improving nutrition in children affected by malnutrition/MND. However, outside of nutrition trials there is a challenge to promote uptake of these interventions. Combining expertise from the UK and China on nutrition and food systems, the focus of the current research is to determine the barriers to uptake of such interventions and to explore novel approaches to promoting their uptake, with the overall aim of improving child nutrition and health. Food is a key part of Chinese culture. Some foods that are considered to be healthful, such as sweet potato, millet, etc., have gone out of fashion and are seen as food for the poor. On the other hand, there may be an inherent resistance to unfamiliar food items for children such as YYB, and concerns about safety of food and biofortification. We will test the acceptance of context specific interventions in children in different age groups. In children from deprived areas, the benefits of early exposure to YYB for enhanced acceptance will be tested in children aged 6 months to 2 years old. Acceptance of biofortified foods (zinc+/iron+ wheat and b-carotene+ sweet potato) will be tested in nursery and school children based on the early exposure and uptake hypothesis. For urban school children at risk of obesity, the intervention will focus on increasing the diversity and optimising the nutrient content of the diet. Feasibility testing of an enhanced diet diversity, food supplementation and biofortification, and nutritional knowledge education will be studied using a survey method at school, family and community levels. Our research will engage with local communities, families and particularly mothers, to explore the determinants of malnutrition and MND, and the social and cultural barriers to uptake of nutrition interventions. When barriers to and drivers of uptake have been identified, photographic exhibitions using a story-telling approach to highlight positive messages will be used to promote the interventions in local communities, with social media campaigns to spread the word and promote engagement. We will develop a scalable food system-based intervention package for malnutrition/MND, and build this into the national food and health policies and guidelines. We will broaden the potential beneficiaries of the nutrition interventions by engaging with experts in Vietnam through communication and capacity-building activities.